- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.14 / $2,034.56 / $2,034.56
| Professional | | $1,942.14 | $2,034.56 | $2,034.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,872.05 / $2,312.56 / $2,322.37
| Professional | | $1,872.05 | $2,312.56 | $2,322.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,692.70 / $3,025.33 / $3,569.89
| Professional | | $2,692.70 | $3,025.33 | $3,569.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.06 / $2,220.06 / $2,590.07
| Professional | | $2,035.06 | $2,220.06 | $2,590.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.05 / $2,312.56 / $3,017.69
| Professional | | $1,887.05 | $2,312.56 | $3,017.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,852.41 / $2,934.48
| Professional | | $29.27 | $1,852.41 | $2,934.48 |